Multihospital Outbreak of a Middle East Respiratory Syndrome Coronavirus Deletion Variant, Jordan: A Molecular, Serologic, and Epidemiologic Investigation

BACKGROUND

An outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) in Jordan in 2015 involved a variant virus that acquired distinctive deletions in the accessory open reading frames. We conducted a molecular and seroepidemiologic investigation to describe the deletion variant's transmission patterns and epidemiology.

METHODS

We reviewed epidemiologic and medical chart data and analyzed viral genome sequences from respiratory specimens of MERS-CoV cases. In early 2016, sera and standardized interviews were obtained from MERS-CoV cases and their contacts. Sera were evaluated by nucleocapsid and spike protein enzyme immunoassays and microneutralization.

RESULTS

Among 16 cases, 11 (69%) had health care exposure and 5 (31%) were relatives of a known case; 13 (81%) were symptomatic, and 7 (44%) died. Genome sequencing of MERS-CoV from 13 cases revealed 3 transmissible deletions associated with clinical illness during the outbreak. Deletion variant sequences were epidemiologically clustered and linked to a common transmission chain. Interviews and sera were collected from 2 surviving cases, 23 household contacts, and 278 health care contacts; 1 (50%) case, 2 (9%) household contacts, and 3 (1%) health care contacts tested seropositive.

CONCLUSIONS

The MERS-CoV deletion variants retained human-to-human transmissibility and caused clinical illness in infected persons despite accumulated mutations. Serology suggested limited transmission beyond that detected during the initial outbreak investigation.

Inclusion of MERS-spike protein ELISA in algorithm to determine serologic evidence of MERS-CoV infection

The Centers for Disease Control and Prevention (CDC) algorithm for detecting presence of serum antibodies against Middle East Respiratory Syndrome coronavirus (MERS-CoV) in subjects with potential infections with the virus has included screening by indirect ELISA against recombinant nucleocapsid (N) protein and confirmation by immunofluorescent staining of infected monolayers and/or microneutralization titration. Other international groups include indirect ELISA assays using the spike (S) protein, as part of their serological determinations. In the current study, we describe development and validation of an indirect MERS-CoV S ELISA to be used as part of our serological determination for evidence of previous exposure to the virus.

Acute respiratory infections among returning Hajj pilgrims-Jordan, 2014

•

Surveillance for respiratory illness in Hajj pilgrims took place in Jordan in 2014.

•

58% of the 125 subjects returning from Hajj tested positive for at least one virus.

•

Rhino/enterovirus was the most commonly detected viral pathogen (47% of subjects).

•

No cases of Middle East Respiratory Syndrome coronavirus were detected.

Background

The emergence of Middle East Respiratory Syndrome coronavirus (MERS-CoV) has prompted enhanced surveillance for respiratory infections among pilgrims returning from the Hajj, one of the largest annual mass gatherings in the world.

Objectives

To describe the epidemiology and etiologies of respiratory illnesses among pilgrims returning to Jordan after the 2014 Hajj.

Study design

Surveillance for respiratory illness among pilgrims returning to Jordan after the 2014 Hajj was conducted at sentinel health care facilities using epidemiologic surveys and molecular diagnostic testing of upper respiratory specimens for multiple respiratory pathogens, including MERS-CoV.

Results

Among the 125 subjects, 58% tested positive for at least one virus; 47% tested positive for rhino/enterovirus. No cases of MERS-CoV were detected.

Conclusions

The majority of pilgrims returning to Jordan from the 2014 Hajj with respiratory illness were determined to have a viral etiology, but none were due to MERS-CoV. A greater understanding of the epidemiology of acute respiratory infections among returning travelers to other countries after Hajj should help optimize surveillance systems and inform public health response practices.

Deletion Variants of Middle East Respiratory Syndrome Coronavirus from Humans, Jordan, 2015

We characterized Middle East respiratory syndrome coronaviruses from a hospital outbreak in Jordan in 2015. The viruses from Jordan were highly similar to isolates from Riyadh, Saudi Arabia, except for deletions in open reading frames 4a and 3. Transmissibility and pathogenicity of this strain remains to be determined.

Persistence of Antibodies against Middle East Respiratory Syndrome Coronavirus

To determine how long antibodies against Middle East respiratory syndrome coronavirus persist, we measured long-term antibody responses among persons serologically positive or indeterminate after a 2012 outbreak in Jordan. Antibodies, including neutralizing antibodies, were detectable in 6 (86%) of 7 persons for at least 34 months after the outbreak.

Hospital-associated outbreak of Middle East respiratory syndrome coronavirus: a serologic, epidemiologic, and clinical description

BACKGROUND

In April 2012, the Jordan Ministry of Health investigated an outbreak of lower respiratory illnesses at a hospital in Jordan; 2 fatal cases were retrospectively confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) to be the first detected cases of Middle East respiratory syndrome (MERS-CoV).

METHODS

Epidemiologic and clinical characteristics of selected potential cases were assessed through serum blood specimens, medical record reviews, and interviews with surviving outbreak members, household contacts, and healthcare personnel. Cases of MERS-CoV infection were identified using 3 US Centers for Disease Control and Prevention serologic tests for detection of anti-MERS-CoV antibodies.

RESULTS

Specimens and interviews were obtained from 124 subjects. Seven previously unconfirmed individuals tested positive for anti-MERS-CoV antibodies by at least 2 of 3 serologic tests, in addition to 2 fatal cases identified by rRT-PCR. The case-fatality rate among the 9 total cases was 22%. Six subjects were healthcare workers at the outbreak hospital, yielding an attack rate of 10% among potentially exposed outbreak hospital personnel. There was no evidence of MERS-CoV transmission at 2 transfer hospitals having acceptable infection control practices.

CONCLUSIONS

Novel serologic tests allowed for the detection of otherwise unrecognized cases of MERS-CoV infection among contacts in a Jordanian hospital-associated respiratory illness outbreak in April 2012, resulting in a total of 9 test-positive cases. Serologic results suggest that further spread of this outbreak to transfer hospitals did not occur. Most subjects had no major, underlying medical conditions; none were on hemodialysis. Our observed case-fatality rate was lower than has been reported from outbreaks elsewhere.

Hospital-associated outbreak of Middle East respiratory syndrome coronavirus: a serologic, epidemiologic, and clinical description

BACKGROUND

In April 2012, the Jordan Ministry of Health investigated an outbreak of lower respiratory illnesses at a hospital in Jordan; 2 fatal cases were retrospectively confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) to be the first detected cases of Middle East respiratory syndrome (MERS-CoV).

METHODS

Epidemiologic and clinical characteristics of selected potential cases were assessed through serum blood specimens, medical record reviews, and interviews with surviving outbreak members, household contacts, and healthcare personnel. Cases of MERS-CoV infection were identified using 3 US Centers for Disease Control and Prevention serologic tests for detection of anti-MERS-CoV antibodies.

RESULTS

Specimens and interviews were obtained from 124 subjects. Seven previously unconfirmed individuals tested positive for anti-MERS-CoV antibodies by at least 2 of 3 serologic tests, in addition to 2 fatal cases identified by rRT-PCR. The case-fatality rate among the 9 total cases was 22%. Six subjects were healthcare workers at the outbreak hospital, yielding an attack rate of 10% among potentially exposed outbreak hospital personnel. There was no evidence of MERS-CoV transmission at 2 transfer hospitals having acceptable infection control practices.

CONCLUSIONS

Novel serologic tests allowed for the detection of otherwise unrecognized cases of MERS-CoV infection among contacts in a Jordanian hospital-associated respiratory illness outbreak in April 2012, resulting in a total of 9 test-positive cases. Serologic results suggest that further spread of this outbreak to transfer hospitals did not occur. Most subjects had no major, underlying medical conditions; none were on hemodialysis. Our observed case-fatality rate was lower than has been reported from outbreaks elsewhere.

Stillbirth during infection with Middle East respiratory syndrome coronavirus

We conducted an epidemiologic investigation among survivors of an outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in Jordan. A second-trimester stillbirth occurred during the course of an acute respiratory illness that was attributed to MERS-CoV on the basis of exposure history and positive results of MERS-CoV serologic testing. This is the first occurrence of stillbirth during an infection with MERS-CoV and may have bearing upon the surveillance and management of pregnant women in settings of unexplained respiratory illness potentially due to MERS-CoV. Future prospective investigations of MERS-CoV should ascertain pregnancy status and obtain further pregnancy-related data, including biological specimens for confirmatory testing.

Novel coronavirus infections in Jordan, April 2012: epidemiological findings from a retrospective investigation

In April 2012, an outbreak of acute respiratory illness occurred in a public hospital in Zarqa city, in Jordan; 8 health care workers were among the 11 people affected, 1 of who later died. The cause of the outbreak was unknown at the time and an epidemiological investigation including laboratory testing carried out immediately afterthe outbreak was inconclusive. Following the discovery of novel coronavirus infection (nCoV) in the Arabian peninsula in September 2012, stored respiratory and serum samples of patients from this outbreak were retested and the diagnosis of nCoV was confirmed in 2 deceased patients. This paper describes the epidemiological findings of retrospective investigation carried out in November 2012 and highlights the likelihood of nosocomial transmission of nCoV infection in a health-care setting. A total of 2 laboratory-confirmed and 11 probable cases were identified from this outbreak of whom 10 were HCWs and 2 were family members of cases.

Emergence of plasmid-mediated multidrug resistance in epidemic and non-epidemic strains of Salmonella enterica serotype Typhi from Jordan

BACKGROUND

Enteric fever caused by Salmonella enterica serovar Typhi has not been adequately explored in Jordan.

METHODOLOGY

In this study we investigated antibiotic resistance patterns and resistance determinants coupled with fingerprint methods of forty-eight isolates of S. Typhi obtained from 113 patients with suspected enteric fever admitted at six governmental hospitals in different directorates in Jordan. Twenty-four isolates were from an outbreak of typhoid fever that occurred between October 2004 and January 2005, and another twenty-four were from sporadic cases from 2005.

RESULTS

All isolates of S. Typhi were resistant to streptomycin. A multidrug resistant (MDR) pattern of ampicillin, chloramphenicol, co-trimoxazole with tetracycline and streptomycin (R-type ACCoTS) was found in 58% of the epidemic strains causing the outbreak and in 98% of the strains from sporadic cases. MDR isolates harbored a single IncHI1 plasmid containing a class 1 integron (dfrA7). Plasmid conjugation studies demonstrated a genetic transfer of resistance (ACCoT). S. Typhi isolates were all sensitive to fluoroquinolones and cefotaxime, the alternative drugs recommended for treatment of typhoid fever. The genomic analysis using PFGE showed: a) the outbreak was caused by an introduced circulating clone with/without an MDR plasmid, and b) isolates from the sporadic cases from 2005 are the same MDR clone that persisted and spread in the country.

CONCLUSION

The emergence of MDR S. Typhi strains is a majorn important public health issue in Jordan. This study should guide selection of effective antibiotic therapy for the treatment of typhoid and monitoring of the spread of MDR of S. Typhi.

Causes of visual impairment and blindness among the middle-aged and elderly in northern Jordan

Causes of bilateral low vision [BLLV] and bilateral blindness [BLB] were investigated among 720 outpatients aged > 45 years in Irbid, Jordan, between July 1999 and October 2000. All received full ophthalmic examinations. BLLV was defined as visual acuity < 6/18 but > 3/60 in the better eye; BLB as acuity < 3/60 in the better eye. The leading cause of BLB and BLLV was cataract. Refractive error was the second major cause of BLLV. Other common causes were diabetic retinopathy and glaucoma. Age-related macular degeneration was the single cause of BLB and BLLV for only 1.6% and 2.8% respectively. A population-based survey of BLB and BLLV in the elderly, yearly vision examinations and an ophthalmic education programme are recommended.

Causes of visual impairment and blindness among the middle-aged and elderly in northern Jordan

Causes of bilateral low vision (BLLV) and bilateral blindness (BLB) were investigated among 720 outpatients aged > 45 years in Irbid, Jordan, between July 1999 and October 2000. All received full ophthalmic examinations. BLLV was defined as visual acuity < 6/18 but > 3/60 in the better eye; BLB as acuity < 3/60 in the better eye. The leading cause of BLB and BLLV was cataract. Refractive error was the second major cause of BLLV. Other common causes were diabetic retinopathy and glaucoma. Age-related macular degeneration was the single cause of BLB and BLLV for only 1.6% and 2.8% respectively. A population-based survey of BLB and BLLV in the elderly, yearly vision examinations and an ophthalmic education programme are recommended.

Sinusitis as a cause of orbital cellulitis

To determine the importance of sinusitis as a cause of orbital cellulitis, the causative organisms and peak age of occurrence, 25 patients hospitalized with orbital cellulitis (ages 8 months to 17 years; 80%, 1-4 years) were studied. Complete blood counts were carried out and radiographic sinus examinations and eye swabs (for culturing) performed prior to antibiotic treatment. Sinusitis was evident in 72% of the patients. Eye swab cultures indicated 80% had streptococcal, staphylococcal or enterococcal infection. The data indicate that sinusitis is an important cause of orbital cellulitis. The most common causative organisms were Streptococcus viridans (44%) and Staphylococcus aureus (32%). Initial antibiotics should therefore cover both organisms.

Sinusitis as a cause of orbital cellulitis

To determine the importance of sinusitis as a cause of orbital cellulitis, the causative organisms and peak age of occurrence, 25 patients hospitalized with orbital cellulitis (ages 8 months to 17 years; 80%, 1-4 years) were studied. Complete blood counts were carried out and radiographic sinus examinations and eye swabs (for culturing) performed prior to antibiotic treatment. Sinusitis was evident in 72% of the patients. Eye swab cultures indicated 80% had streptococcal, staphylococcal or enterococcal infection. The data indicate that sinusitis is an important cause of orbital cellulitis. The most common causative organisms were Streptococcus viridans (44%) and Staphylococcus aureus (32%). Initial antibiotics should therefore cover both organisms.